Synopsis

Although electronic communication between clinicians and patients can be a convenient, inexpensive way to improve access to care, manage chronic illness, and increase patient satisfaction, it is still uncommon in U.S. physician practices. Commonwealth Fund–supported researchers identified barriers that have limited physicians’ use of email and e-visits and note that newer payment models that compensate for this kind of care will be key in spurring adoption.

The Issue

Besides simplifying appointment scheduling and prescription refills, electronic communication offers patients an alternative to face-to-face office visits, when clinically appropriate. Yet in 2008, fewer than 7 percent of physicians reported regularly communicating with patients through email or other electronic means. A major barrier is the lack of reimbursement for the time spent by providers on e-consults. For this study, researchers interviewed medical group leaders to identify the advantages and disadvantages of e-communication programs and what actions are necessary to help facilitate wider implementation.

Key Findings

The desire to provide patient-centered care was the primary motivation cited for setting up e-communication programs. The six practices chosen for in-depth interviews used the programs not only for refilling prescriptions, scheduling appointments, and responding to patient questions, but also for providing clinical care that might otherwise require an office visit.

Although lack of reimbursement for time spent on e-communication or e-visits can be a barrier to their implementation, one fee-for-service practice got around this by charging patients an annual fee of approximately $500. Another charged patients a low fee for e-visits and negotiated reimbursement with some private insurers to cover those e-visits. Meanwhile, the two groups that received capitated payments (a set amount per patient) were able to realize cost savings by shifting some office visits to e-visits.

Some providers in the study described the “feeling of never being done,” according to the authors. The number of messages reaching a physician varied significantly, from five to 10 per day at Colorado Permanente to 20 to 50 per day at Fairview Health Services. A triage system set up in the Colorado practice cut down on the number of messages reaching physicians each day.

Addressing the Problem

"Practice redesign and new payment methods are likely necessary for electronic communication to be more widely used in patient care," the authors write. To reduce the time burden that e-communication can place on physicians, some practices use nurses or care managers to triage patients' messages. Practices also can help by formally scheduling an hour or so each day for a physician to deal with e-communication. Noting that the fee-for-service payment model typically reimburses doctors for office visits but not for virtual care, the authors point to new capitated payment models, such as the patient-centered medical home, that encourage providers to use e-communication to expand patients’ access to care and improve management of chronic illness―without negatively affecting reimbursement.

About the Study

In this qualitative study, researchers interviewed leaders at 21 diverse medical groups that use electronic communication programs to help deliver primary care. Additional interviews were conducted with providers and staff at six of these groups, including Colorado Permanente Medical Group, a multispecialty group practice; Fairview Health Services, a large group practice using a fee-for-service model; and Southcentral Foundation, a nonprofit medical group paid through a fee-for-service model with a government supplement. The researchers also queried six leaders from national and regional health plans about their intentions to pay for electronic communications.

The Bottom Line

Electronic communication programs are convenient, inexpensive, and improve access to care, yet relatively few medical practices have them. Wider implementation requires practice redesign to enable better message management, as well as new payment models that compensate providers for e-visits.

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Mission

The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.